Did Mozart Die of Kidney Disease?

A Review From the

Bicentennial of His Death1
Edward N. Guillery2

and wrote that Mozart required a “nightjacket which

EN. Guillery, Division of Pediatric Nephrology, Depart- he could put on frontways, since on account of his
ment of Pediatrics, University of Iowa Hospitals and swollen condition he was unable to turn in bed” (1).
Clinics, Iowa City, IA. Mozart said to her “Why, I have already the taste of
death on my tongue.” Cold poultices were placed on
(J. Am. Soc. Nephrol. 1992; 2:1671-1676)
Mozart’s “burning head,” which, it seemed to Haibel,
caused him to become unconscious, in which state
he remained for 2 h until he died. She added: “His
ABSTRACT last movement was an attempt to express with his
There has been a tremendous interest in the circum- mouth the drum passages in the Requiem” (1).

stances of Mozart’s death. Theories of head trauma,

poisoning, heart disease, and most prominently,
RHEUMATIC FEVER AND SUBACUTE BACTERIAL
renal failure have all appeared recently in scholarly
ENDOCARDITIS THEORIES
musicology publications, the lay press, and the med-
ical literature. The purpose of this article is to present Rheumatic fever and subacute bacterial endocar-
ditis (SBE) have been proposed as causes of Mozart’s
the evidence behind each of these theories. Al-
death. The rheumatic fever theory was originally
though this review cannot be considered compre-
developed by C. Bar (2) and has been supported by
hensive, with the overview provided, it will be shown others (3, 4). It has been appropriately criticized (5).
that few conclusions can be drawn. The basis of the theory is in several observations.
Key Words: Mozart. renal failure. poisoning Mozart’s father, Leopold, wrote a letter when Mozart
was 10 yr old and described a febrile illness with

W olfgang Amadeus
age of 35 yr following
Mozart died in 1 79 1 at the
a 2-wk illness. Public
arthralgias
lation
that lasted
of Otto Deutsch’s
1 0 days.
work,
In the English
this illness
trans-
is described
as rheumatism (1). A letter written by Leopold to his
interest in Mozart was raised during the just-passed daughter Nannerl in 1 784, when Mozart was 28 yr
bicentennial of his death, perhaps in part from the old, describes fevers and diaphoresis; Leopold writes
film Amadeus, and a flood of reports discussing the that “. . a number
. of people caught rheumatic fever,
circumstances of his death has resulted. Some be- which became septic when not taken in hand at once”
lieve that Mozart died in renal failure, but the details and quotes his son as writing “Four days running at
of the cause have resulted in much controversy. This the very same hour I had a fearful attack of colic,
review will present the various theories and show which ended each time in violent vomiting” (6). Rheu-
that no definite conclusions can be drawn. maticfever in the 18th century was a nonspecific
The events of Mozart’s terminal illness are known term used to refer to any febrile illness with joint
to us from a letter by Sophie Haibel, the sister of pains.
Mozart’s wife Constanze. It was written in 1825, 33 Another observation is that Mozart had several
yr after his death, to Georg Nikolaus von Nissen, tooth abscesses (November 1 770, December 1774,
Constanze’s second husband and one of Mozart’s and May 1790). Each could have led to SBE in a
biographers. Haibel was present during this illness patient with a heart already damaged by rheumatic
fever. Dr. Mathias von Sallaba was called to see
‘Received January 21, 1992. Accepted February 28, 1992. Mozart about a week before his death and diagnosed
2 correspondence to Dr. EN. Guillery, Division of Pediatric Nephrology, Depart- hitzigesfrieselfieber, which means heated miliary
ment of Pediatrics, University of Iowa Hospitals and Clinics. Iowa City, IA 52242. fever. This diagnosis was entered in the Register of
1046-6673/0212-1671 $03.00/a Deaths. In the context of the time, this diagnosis is
Joumal of the American Society of Nephrology
Copyright C 1992 by the American Society of Nephrology said to be completely nonspecific. There has been

Journal of the American Society of Nephrology 1671

Mozart and Kidney Disease .r

much debate about whether or not a rash or petechiae adults). Historical sources and examination of por-
are implied in the term (3,5,7-9). Constanze and traits reveal that Mozart’s main facial features were
Sophie did note edema, and this has been attributed a straight forehead with anteriorly placed eyes,
to heart failure from rheumatic heart disease. Many marked cheekbones, and a prominent nose and up-
authors note that Mozart was bled near the time of per lip. The cranium Puech et al. have examined is
his death, which would have, no doubt, hastened his shown, by imposition of its image onto a portrait, to
demise if he were in heart failure from rheumatic coincide with Mozart’s features.
heart disease and SBE. This is the sum of the evi- A healing temporoparietal fracture on the left side
dence for rheumatic fever/heart disease and SBE. with an extradural hematoma is used as an expla-
The letter of 1 784 has been used as evidence for nation for the death of Mozart. Puech et al. propose
urinary obstruction and pyelonephritis (hence, the that he sustained the fracture as a result of a fall he
colic). Renal failure could have been the cause of the later forgot. There are some aspects of Mozart’s ter-
edema that the sisters noted and seems more likely minal illness that cannot be explained. Why would
than SBE when considered with other observations he have been edematous and febrile? Banerjee pro-
to be cited later. The notable absence of any mention poses that this fracture may have occurred more than
of dyspnea (Mozart was said to have sung during his a year before his death and explains Mozart’s head-
final illness, although Stafford doubts this story [8]) aches, which started in the spring of 1 790, his weak-
also argues for edema from a hypooncotic state rather ness, fainting spells, and paralysis that some claim
than cardiogenic edema. In order to diagnose SBE, occurred after he took to his deathbed on November
one would hope for more than the presence of fever, 20, 1 79 1 (1 3). Perhaps the proposed head trauma
but that is all we can conclude from Haibel’s account, explains some of the symptoms Mozart complained
As for rheumatic fever in childhood, only two of the of in his last year, but one is hard pressed to account
Jones minor criteria are met (fever and arthralgias). for Mozart’s death on the basis of this injury.
The initial illness of rheumatic fever lasts 3 to 4 wk;
the illness Mozart had as a child lasted only 10 days.
HEAVY METAL POISONING THEORIES
Other illnesses that can cause fever and arthralgias
are bacterial infections ( Yersinia, Salmonella, and The theories of Mozart having been poisoned have
Shigella organisms-all unlikely with the absence circulated since shortly after his death. They are
of other symptoms) and viral infections (rubella, hep- based on a number of reports by people close to
atitis, echovirus, and Enterovirus species-all quite Mozart. Vincent and Mary Novello wrote a diary of
possible). their conversations with Constanze Mozart in 1829
( 1 4). Vincent was a composer and publisher, and he
and his wife planned a biography of Mozart. Mary
HEAD TRAUMA THEORY wrote in her diary:

Recently, Puech et al. have published claims that Some six months before his death he was possessed
they have examined the skull of Mozart and that it with the idea of his being poisoned-’! know I must
shows evidence of craniofacial dysmorphism ( 1 0, 1 1).
die’ he exclaimed,
, ‘someone has given me acqua tof-
A healing temporoparietal fracture on the left side fana and has calculated the precise time of my death-
for which they have ordered a Requiem, it is for myself
with the imprint from a calcified epidural hematoma
that I am writing this.’
is described. The veracity of their claim depends
entirely on whether or not they have examined Moz- Acqua toffana is a slow poison containing arsenic
art’s skull. Mozart was buried in an unmarked grave and lead oxide, invented by a Neapolitan woman,
in St. Marx’s cemetery in Vienna. According to Day- Tofana, and “brought to light in 1 659 by a Roman
ies, Mozart’s skull was marked with a piece of wire police inquiry into the doings of a group of conven-
by the sexton of St. Marx’s, Joseph Rothmayer (12). iently widowed women” (14).
When the grave was reopened in 1 80 1 he removed , H.C.R. Landon has reviewed the evidence for poi-
the skull and kept it as a “sacred relic.” It was ob- soning in a recent book (1 5). He cites the above
tamed by Professor Joseph Hyrtl, a Viennese anato- evidence and uses the gossip that circulated in Vi-
mist and anthropologist, remained in his family’s enna in the early 1 820s, precipitated by Antonio
possession until 1899, and by 1901 was acquired by Salieri’s unsuccessful suicide attempt and reported
the Mozarteum in Salzburg (10). (although undocumented) confession to killing Moz-
By an assessment of dental wear, the skull is art, to show how the poisoning theory was propa-
thought to have belonged to someone who died be- gated. He cites a number of entries into Beethoven’s
tween the ages of 25 and 40 yr. The skull is said to Konversatlonshefte-the book the deaf composer
be typical of the male South German brachycephalic. used to “converse” with visitors. We can learn from
A distinctive feature is premature synostosis of the this book that the theory that Salieri poisoned Mozart
metopic suture, a rare occurrence (1 in 10,000 was an item of gossip in Vienna from 1823 to 1825.

1672 Volume 2’ Number 12” 1992

 Guillery

At this time, near the end of his life, Salieri was his own. With the death of his wife in February 1791,
hospitalized as insane. What is the value of this he arranged to have an agent, acting on his behalf
evidence, much of it collected decades after Mozart’s (albeit anonymously), approach Mozart and commis-
death? How much of it is idle gossip leading people sion him to write a Requiem Mass that he could have
like Richard Wagner to write in 1 830 that most mu- performed as his own composition in honor of his
sicians believed that Mozart was poisoned by Salieri? wife. Why Mozart should have thought he was being
(1 3) Beyond hearsay, there is little if any evidence. poisoned has not been explained.
Salieri himself denied the allegations (1 5). The motive Mozart’s association with the Freemasons is well
seems to be there: these two men were rivals. Leopold known. Freemasonry was popular in late- 1 8th cen-
wrote in 1 786 to Mozart’s sister of Le Nozze di Fl- tury Austria, as it was in the rest of Europe and the
garo: Americas. This history as it relates to Mozart has
been well reviewed by Landon (1 5, 1 7) and Stafford
It will be surprising if It is a success, for I know that (8). The theory that Mozart was poisoned by the
very powerful cabals have ranged themselves against Masons first appeared in Otto Jahn’s biography of
your brother. Salieri and all his supporters will again
1 89 1 and was propagated by Dr. Mathilde Ludendorff
try to move heaven and earth to down his opera. (6)
in 1 936. This absurd theory is actually Nazi propa-
ganda, the purpose of which was to show that Mozart
The two men, however, also enjoyed an amicable
was a good German and a victim of a Jewish-Chris-
professional relationship. Mozart wrote to his wife in
tian and Masonic conspiracy (8). Ludendorff pro-
October of 1 79 1 of taking Salieri and the great so-
posed that Mozart’s long-time supporter Baron van
prano Madame Cavalieri to a performance of his
Magic Flute and having a very pleasant time. Swieten and other Masons plotted to poison Mozart
In his excellent review of the various poisoning with the help of the mysterious stranger. Fellow Ma-
son Nissen covered up the murder with his biography
theories, Davies shows how these myths have been
kept alive through the years (16). Alexander Pushkin and then married Mozart’s widow. Baron van Swie-
wrote a play called Mozart and Salieri, and Rimsky- ten then saw to it, according to this theory, that
Mozart was buried in an unmarked pauper’s grave
Korsakov based an opera on this play. As recently as
1953. the Soviet musicologist Igor Beiza kept the with the skull removed, as dictated by Masonic law.
If anyone should be credited for supporting Mozart
theory alive with the unconfirmed statement that the
Viennese musicologist Guido Adler had discovered a and his widow, it is Baron van Swieten. This theory
written confession of Salieri’s (needless to say, no is malicious nonsense.
one has ever seen this document). The play Amadeus More recently, the poisoning theory has been given
by Peter Shaffer burst upon the scene in 1 979 and new life with the proposal, by Dr. Ian James of the
became a sensational film directed by Milos Fore- Royal Free Hospital in London, that Mozart died of
man; this served to keep the poisoning theory very iatrogenic antimony poisoning. He claims Mozart was
much alive. Far from being a mediocrity. as suggested prescribed an antimony compound to treat the severe
by this play, Salieri was highly regarded and suc- depression or melancholia from which he suffered.
cessful in his time. What he truly thought of himself, When Mozart died, he left a large bill for medicines
we will never know. As Chamber Composer and con- from the Viennese apothecaries, although there is no
ductor of the Italian Opera, he composed about 40 record of what was prescribed. Franz Xaver Niemet-
operas. Salieri’s pupils included Beethoven, Schub- schek, an early biographer, wrote in 1 808: “In Prague
ert, and Liszt. Although his music may sound second Mozart fell ill and dosed himself ceaselessly” ( 1 ). The

rate next to Mozart’s, he had a successful career. symptoms of antimony poisoning are coughing, ar-
Considering all of the evidence cited above, it can thralgias, arthritis, myalgias, headache, fainting, ap-
only be concluded, as Mary Novello concluded, that nea, abdominal pain, vascular collapse, facial edema,
Salieri’s guilt from having treated Mozart badly led and skin rash (18). As with all of the heavy metals,
his deranged mind to accuse himself of far greater chronic ingestion can cause renal tubular dysfunc-
crimes. tion and renal failure.
There remains a question: Constanze claimed that Others have proposed iatrogenic mercury poison-
Mozart said he was being poisoned with acqua tof- ing with the mercury given for syphilis. The idea that
fana and that this was in connection with the Re- Mozart had syphilis is doubted by most authors (19).
quiem, which was commissioned by an anonymous Mercury, as is the case with lead and arsenic, may
stranger; could this have happened? This mysterious lead to a polyneuropathy if chronically ingested.
messenger, in one of those instances of history show- These heavy metals can also cause a gait disturbance
ing that fact is stranger than fiction, was an agent of and tremors, symptoms not noted for Mozart. Moz-
a Count Franz von Walsegg. a minor aristocrat who art’s handwriting and manuscripts have been ana-
had the habit of commissioning works anonymously lyzed extensively, and there is no evidence of tremor
and then passing them off to friends and family as or paraplegia. Mercury can also cause slurred speech,

Journal of the American Society of Nephrology 1673

Mozart and Kidney Disease

visual changes, hearing loss, and eventually, mental The bacterial examination of these cases has not been

deterioration, none of which were observed. very satisfactory-no unanimity has been reached as
to the organisms. On the other hand, there is a large
Lead and arsenic, which are the ingredients of
group in which the lesions are an expression of per-
acqua toffana, cause (for arsenic) a metallic taste in
verted metabolism. (28)
the mouth, a peripheral neuropathy, anemia, gas-
trointestinal disturbances, and multiple skin afflic- Davies then claims that Mozart died during an epi-
tions ( 1 8). Mozart did remark shortly before he died demic, this based only on a letter written by Dr.
that he had the “taste of death” in his mouth; could Guldener von Lobes in defense of Salieri in 1824, 33
this have been the metallic taste? Again, he had no yr after Mozart’s death. He wrote that Mozart had
evidence for a peripheral neuropathy. Lead can cause fallen ill “with a rheumatic and inflammatory fever
colicky abdominal pain. nausea, vomiting, a metallic which had also attacked a great many inhabitants of
taste in the mouth, constipation, limb pain, and later Vienna at the time” ( 1 6). This doctor did not examine
in chronic ingestion, a peripheral neuropathy (18). Mozart, and so, his credibility is dubious at best.
With all of these heavy metals except antimony, we Karhausen has emphasized the lack of evidence for
would expect mental deterioration and the evidence an epidemic at the time (7) and quotes the work of
of a peripheral neuropathy near the end. Mozart was Bar (2). For November and December 1 79 1 Bar found ,

relatively lucid until 2 h before his death and was 656 deaths in the mortality statistics of Vienna. Dur-
composing until the day of his death. Of all of these ing that period, this represents a 1 7% increase over
substances, antimony seems the most possible. We the previous months. Of these 656 cases, there was
are again confronted by a paucity of evidence; Dr only one listed with the diagnosis of hitzigesfriesel-
James’s theory is compelling but based on the thin fieber-that was Mozart’s case. Furthermore, HSP
evidence of headache, edema, Mozart’s depression is clearly not an epidemic illness (29). Davies goes on
(which may have simply been normal variance of to assume that there was a polyarthritis and a pete-
mood 120]), and records of unpaid pharmacy bills. chial rash present with only tenuous indirect evi-
dence. Sophie Haibel told the Novellos that Mozart’s
arms and legs were “inflamed and swollen” ( 1 4). We

RENAL FAILURE THEORIES have no way of knowing what an untrained observer

in the 18th century might mean by inflammation; it
Several authors have presented strong cases for
is difficult to conclude that there was a polyarthritis,
Mozart having died of complications of renal disease
although this point is certainly controversial and is
(5,12,21-25). There is a divergence of opinion about
being vigorously debated (7,9). As for a skin rash,
the exact cause, and several have been proposed.
none was described on Mozart. The vague diagnosis
Clein presented his case for postinfectious glomeru- of hitziges friesefieber is too nonspecific to make
lonephritis in 1959 (22). The evidence to support his
that inference (7), although Davies makes such an
case has been widely cited and consists chiefly of inference based on the terminology of 1 9th century
letters describing upper respiratory infections of pathologists (9). Davies simply states “A skin rash
childhood. Mozart never reported gross hematuria, was also present” without citing any further evidence
and so, in the absence of a urinalysis or a renal (2 1 ). Davies adds that HSP could have been more
biopsy, one is hard pressed to diagnose glomerulo- common in Mozart’s time. This is completely specu-
nephritis. lative; there is no epidemiology, as there is with rheu-
Davies has used the letter of 1 784 describing fever, matic fever, showing a decline in the incidence of
colic, and “rheumatic fever,” along with letters writ- HSP. Considering these facts, although HSP is a pos-
ten to fellow Mason Michael Puchberg between July sible diagnosis, it is so rare and the evidence so thin
1 789 and August 1 790 describing fever, chills, tooth- as to render the theory untenable.
aches, headaches, and “rheumatic pains,” to propose Wheater explores the possibility that Mozart had
his rather more elaborate theory that Mozart died of renal tuberculosis as a cause for renal failure, with-
Henoch-SchOnlein purpura (HSP), which resulted out pulmonary involvement (5). This theory would
from streptococcal infections (16,21). The basis of follow from a history of erythema nodosum that Moz-
this theory is in a number of faulty assumptions. The art may have had in childhood (30). Mozart’s edema
first is that Mozart had numerous streptococcal in- could have resulted from tuberculous peritonitis, his
fections. There is no way of knowing this; many chronic illness from a cerebral tuberculoma, and his
other pathogens could have caused some or all of the death from miliary tuberculosis. It is ironic that Day-
febrile illnesses and cases of pharyngitis that Davies ies should say of this theory “the above sequence of
cites. The second faulty assumption is that HSP and events seems far too remote for further considera-
streptococcal infection are related. This once-postu- tion” (2 1 ). Wheater also feels that tuberculosis does
lated association has been convincingly disproved by not explain all of the features of Mozart’s final ill-
many authors as long ago as 1961 (26,27). Sir Wil- ness.
liam Osler even anticipated this later work in 1914; Perhaps more likely and consistent with the letters

1674 Volume 2 “Number 12’ 1992

 Guillery

cited above is the idea that Mozart had recurrent REFERENCES

urinary tract infections with pyelonephritis leading
to chronic renal failure. This theory was first pro- 1 . Deutsch OE. Mozart, a documentary biography
(translated by BlOm E, Branscombe P. and Noble
posed by Barraud (25), with the additional proposal J). Stanford: Stanford University Press: 1965.
by Greither of obstructive uropathy (3 1 ), and has 2. Bar C: Mozart, Illness-Death-Burial. Salz-
been expanded upon by Karhausen in connection burg: International Stiftung Mozarteum: 1966,
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3. Sakula A: “Amadeus”-Was Mozart poisoned?
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History Med 1980;Jan/Feb:6-9.
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married Nissen after the death of Mozart), an illus- 5. Wheater M: Mozart’s last illness-a medical di-
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6. Anderson E. The Letters of Mozart and His Fam-
shown; there is an absence of the auricular lobule, ily. 1 st Ed. London: Macmillan and Co. , Ltd;
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CONCLUSIONS Times 1984:125:437-441, 554-561.
1 7. Landon HCR. Mozart, The Golden Years. Lon-
There are very few conclusions that can be drawn don: Thames and Hudson: 1989.
from this debate. It seems quite possible that Mozart 1 8. Haddad LM, Winchester JF. Clinical Manage-
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Journal of the American Society of Nephrology 1675

 Mozart and Kidney Disease

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“ The vertebrate brain is a most wonderful mechanismfor wrestingfreedom out of necessity, and the vertebrate
brain attains its greatest efficiency in man. But the evolution of the vertebrate brain parallels the evolution
of the neuromuscular system. and the evolution of the neuromuscular system in all its complexities has been
made possible by the evolution ofan internal environment ofconstant composition. I need not emphasize that
this Internal environment is in effect synthesized by the kidneys, that every drop of this environment is
resyntheslzed by the kidneys some sixteen times a day. Historically and physiologically, consciousness and
urine formation are inseparable.”

Homer W. Smith, “Dc Urina,” Kaiser Foundation Medical Bulletin, 1958:6:1.

1676 Volume 2’ Number 12’ 1992